dr t j beale royal national throat nose & ear and uclh … · 2018-10-26 · imaging protocol:...
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Salivary ultrasoundDr T J Beale
Royal National Throat Nose & Ear and UCLH Hospitals London UK
Two main groups ofpatients with presenting symptoms of:
• Obstructive or chronic inflammatory symptoms (salivary colic)
• or a mass…….. ? Salivary in origin
Some overlap between groups
Salivary Colic Tips…… Always
• Take a brief history from the patient -”strange tasting saliva” -“swelling under tongue” -”swelling associated with meals” Examine: - the floor of mouth with submandibular colic - bimanual palpation if more proximal stone - the swelling (what does it feel like?) why?
Examine: - the cheek with parotid swelling why?
Diagnostic Imaging AlgorithmSalivary colic
US
Calculi Sialadenitis Mass
FNA
Stricture No stricture Inflammatory Neoplastic
Conservative Management
Sialography Sialography
Minimally Invasive Intervention
MRI or (CT)
Surgery (LA/GA)
Normal but symptoms
Surgery
Why ultrasound initially?
• Usually gives the answer.. and quickly! • Salivary glands superficial … ideal • Highest resolution • Combined with FNA…..if mass seen
• But operator dependent
Start with submandibular salivary gland
• Why?
Submandibular Sialolithiasis
• 80% of all salivary calculi.
• 85% of calculi occur within the SM duct: 30% ductal orifice 20% mid-duct 35% at hilum
• 80% of SM calculi are radioopaque on plain film.
• NB 25% of patients have multiple calculi!!
Normal Anatomy of the Submandibular & Sublingual Spaces: Coronal Section
MR Coronal Anatomy
MR Submandibular Anatomy
Ultrasonography: SM Gland
TECHNIQUE • 10-15 MHz linear probe or 6MHz
curvilinear • Coronal section:
Probe moved from hyoid bone to the submental area.
• Oblique sagittal section:-
Probe parallel to ramus & body of mandible
Coronal Ultrasound Anatomy: Submandibular Gland
Coronal US image of a normal SM gland.
- - - Mylohyoid muscle -- - Hyoglossus muscle Facial Artery
SMG
Mandible
Coronal Ultrasound Submandibular gland
Coronal US Anatomy Floor of mouth
Submandibular Calculi
NORMAL CALCULUS
Diagnostic Pitfalls
• SMG obstruction may be due to a FOM carcinoma
or malignancy of the sublingual gland.
• 25% of patients have multiple calculi. Examine whole ductal system and the contralateral side.
• The lingual vein may be mistaken for a distended SM duct
Pitfall: Obstruction of SM duct by Tumour of Sublingual Gland
Dilated SM duct 1= Mylohyoid muscle
Adenoid cystic carcinoma of sublingual gland
Sagittal ObliquePosterior Anterior
SMG 11
Coronal floor of mouth
Normal Tumour
Sublingual Adenoid cystic (ACC)
Diagnostic Pitfalls
• SMG obstruction may be due to a FOM carcinoma
or malignancy of the sublingual gland.
• 25% of patients have multiple calculi. Examine whole ductal system and the contralateral side.
• The lingual vein may be mistaken for a distended SM duct
Pitfall :Bilateral calculiCoronal US SMG hilar
Pitfall multiple calculi sagittal
Sagittal US image showing a dilated SM duct (red arrows) secondary to obstruction by a cluster of calculi (white arrows). Note the inflamed SMG (yellow arrows). --- Mylohyoid muscle
Pitfall: multiple calculiUS sagittal oblique
Pitfall: Lingual Vein versus Submandibular duct
The lingual vein & submandibular duct both pass between hyoglossus & mylohyoid muscles.
OBLIQUE SAGITTAL
Pitfall ..Focal Sialadenitis?
US images demonstrating a hypoechoic inflamed superficial lobe of the left SMG yellow arrows) with dilatation of the intraglandular duct (white arrows) & increased Doppler flow.
Submandibular Sialadenitis
Oblique sagittal US images showing a uniformly hypoechoic inflamed right SMG (with increased vascularity on colour Doppler) & normal echogenicity of the left gland. Arrow indicates the lingual vein between the mylohyoid & hyoglossus muscles.
RIGHT LEFT
RIGHT
Pitfalls:Sialadenitis versus Tumour
A B
Parotid Sialolithisis
• 20% of calculi occur in the parotid duct.
• < 50% of stones are radioopaque on plain film.
Normal Anatomy Of the Parotid Region
Parotid Anatomy
Ultrasound Anatomy: Parotid Gland
Axial US image of a normal parotid gland (1). 2= Mandible 3= Parotid duct 4= External carotid artery 5= Styloid process
1
2
3
45
Ultrasound Anatomy: Parotid Gland (coronal)
External carotid artery Retromandibular vein
Technique
Parotid obstruction
Obstructive Parotid Sialadenitis Secondary to Calculus
1
Note thick wall of chronically inflamed duct
Post & pre sialogogue images of the parotid demonstrates the ductal anatomy.
Tip: use sialogogueParotid Gland
Useful Tip: US the Parotid Duct Orifice
Masseter muscle
0.16cm calculus at the ductal orifice
Buccal fat pad
PAROTID US FOLLOWING SIALOGOGUE
Summary: salivary colic
• History and examination important
• US Technique +/- sialogogue probe angle impt and gentle pressure Examine all 6 major salivary glands ..always
• Do not forget obstructing tumour • Do not forget multiple calculi • Do not forget bilateral calculi
Two main groups ofpatients with presenting symptoms of:
• Obstructive or chronic inflammatory/ autoimmune salivary symptoms (salivary colic)
• or a mass…….. ? Salivary in origin
Some overlap between groups
Background: Tumours of the Parotid:
• 80% of all salivary neoplasms • 80% benign • 80% superficial lobe (usually in the tail). • 80% pleomorphic adenoma
• (5-10%) Warthin’s tumour (bilateral in 10-20%)
• Mucoepidermoid the most common malignancy
Parotid US: Localization of Lesion Questions to answer
• Intra- or extraparotid? • Superficial versus deep? • Single or multiple • Unilateral or bilateral • Cystic or solid • Ill- defined or well defined
• ? + nodes
Imaging Algorithm: Parotid MassPAROTID MASS
US
Superficial Lobe Mass Deep Lobe Mass
FNA FNA
MRIBenign Malignant
SURGERY
Pitfalls in salivary imaging
Deep lobe extent (parotid) Atypical Facial N palsy (parotid) Cystic salivary lesions Inflammation v tumour Sublingual/minor salivary tumours Lymphoma in Sjogrens
Deep Lobe of Parotid Tumour Tip of the iceberg!
.
Tip : Use a curvilinear probe
Deep lobe of Parotid TumourAxial T1
= Fat signal in PPS
Coronal T1
Axial STIR
Curvilinear probe and spinal needle for FNA
Common Tumours Pleomorphic Adenoma
Note the hypoechoic lobulated outline & posterior acoustic enhancement.
Recurrent pleomorphic
Coronal T1W Coronal T2W
Recurrent Pleomorphic Adenoma
Coronal MRI images demonstrating multiple foci of recurrent pleomorphic adenoma in the left submandibular region (arrows).
Recurrent PSA
MRI salivary tumours
Benign features: • Low signal rim • Round/lobulated mass • High signal on T2 Malignant features: Irreg tumour margins Invasion Heterogeneous & hypointense signal on T2
Warthin’s Tumour
Note the variable appearance of Warthin’s tumour on US. In case 1 the tumour is mainly solid, but contains two small cystic areas (arrows). In case 2 the tumour is almost entirely cystic and contains internal echoes.Case 2: Coronal View
Coronal
Case 1: Axial View Coronal View
Warthins Tumour
NB Male, Smoker Tail of parotid, Bilateral
Single Multiple
Pitfalls in salivary imaging
Deep lobe extent (parotid) Atypical Facial N palsy (parotid) Cystic salivary lesions Inflammation v tumour Sublingual/minor salivary tumours Lymphoma in Sjogrens
Pitfall:“inflammatory” parotid cyst
Diagnosis?
Mucoepidermoid
Coronal US image of a cystic parotid mass.
T h i n k mucoepidermoid
Diagnosis?Pseudocystic mass
Remember lymphoma if pseudocystic mass or new mass in Pt with Sjogrens
Parotid Lymph Node Metastases
Note chaotic hypervascularity of the intraparotid lymph n o d e s . K n o w n r e n a l carcinoma, suggestive of metastases. C o n f i r m e d w i t h F N A cytology.
Imaging Algorithm: Submandibular Mass
SUBMANDIBULAR MASS
US
FNA
Benign Malignant
MRI
SURGERY
Submandibular Tumour
0.5 x 0.9cm clearly visualised on US.
Adenoid cystic carcinoma on FNA and excision
M
H
M = Mylohyoid muscle, H = Hyoglossus muscle.
Imaging Protocol: Sublingual and Minor Salivary Glands
MINOR SALIVARY GLANDS • MRI is performed in all cases. • CT may be used to demonstrate bony erosion
e.g. palatal tumours. • US may be helpful. Malignancy 50-80%
• Palate > tongue base others v rare (subglottic,sinonasal, EAC)
Imaging Protocol: Sublingual and Minor Salivary Glands
MINOR SALIVARY GLANDS • MRI is performed in all cases. • CT may be used to demonstrate bony erosion
e.g. palatal tumours. • US may be helpful. Malignancy 50-80%
• Palate > tongue base others v rare (subglottic,sinonasal, EAC)
Minor salivary tumour
• 30 year old male • Minute ulcer right hard palate
Palatal Tumour MR v US!
Minor salivary gland tumour
Tongue
Finally Other salivary inflammatory, infective disorders
Diagnosis?
Multiple similar size small hypoechoic foci?
Sjogrens: Always examine all major Salivary glands
Sjögren’s Syndrome: Sialography
MRI Sialogram Conventional Sialogram
Diagnosis?
STIR Coronal Axial Parotid
HIV Sialopathy: Cystic Benign LymphoepithelialLesions (BLEL)
• Multiple bilateral or unilateral cystic & solid lesions of the parotid gland are seen in 3-6% of patients with HIV infection.
• FNA of the cystic fluid is both diagnostic and therapeutic.
• +/- associated cervical lymphadenopathy, adenoidal and tonsillar hypertrophy.
Diagnosis?
Swelling floor of mouth
Coronal
Sagittal
FOM: Atypical Ranula
Herniation of left sublingual gland Herniation of ranula through defect
Herniation of sublingual gland & ranula
A to C coronal USS of floor of mouth
SLG = Sublingual gland, ABG Anterior belly of digastric, R = Ranula
= Mylohyoid
SLG R
R
SLG
ABGABG
ABG
Advances in salivary imagingElastography
• Unfortunately neither strain or shear wave elastography can realiably differentiate benign from malignant.
• Malignant usually stiffer than benign but overlap
Thankyou
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